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Out of Network HUMANA.
ion Services Claim Form
Claim Form Instructions
Most HumanaVision plans allow members the choice to visit an in-network or out-of-network vision care
provider. You only need to complete this form if you are visiting a provider that is not a participating
provider in the Humana network. Not all plans have out-of-network benefits, so please consult your
member benefits information to ensure coverage of services and/or materials from non-participating
providers.
If you choose an out-of-network provider, please complete the following steps prior to submitting the
claim form to Humana. Any missing or incomplete information may result in delay of payment or the
form being returned. Please complete and send this form to Humana within one (1) year from the
original date of service at the out-of-network provider’s office.


When visiting an out-of-network provider, you are responsible for payment of services and/or
materials at the time of service. Humana will reimburse you for authorized services according to your
plan design


Please complete all sections of this form to ensure proper benefit allocation. Plan information may be
found on your benefit ID Card or via your human resources department.


Humana will only accept itemized paid receipts that indicate the services provided and the amount


charged for each service. The services must be paid in full in order to receive benefits. Handwritten
receipts must be on the provider’s letterhead. Attach itemized paid receipts from your provider to the
claim form. If the paid receipt is not in US dollars, please identify the currency in which the receipt
was paid
Please include a copy of your Explanation of Benefits if submitting for a Secondary Insurance Benefit.
Sign the claim form below.
Reimbursements will be mailed to the stored mailing address in the Humana membership system. If
you recently moved or changed your address, please contact the Call Center to update your
information.
Pan
Return the completed form and your itemized paid receipts to:
Humana Vision Care Plan
Attn: OON Claims
P.O. Box 14311
Lexington, KY 40512-4311
Please allow at least 14 calendar days to process your claims once received by Humana. Your
claim will be processed in the order it is received. A check and/or explanation of benefits will be mailed
within seven (7) calendar days of the date your claim is processed
Inquiries regarding your submitted claim should be made to the Customer Service number printed on the
back of your benefit identification card.
Out of Network HUMANA.
Vision Services Claim Form
Patient Information (Required)
Last Name
CIO0UOUOOOOOO OOOO
QDDOIDODIOID OI) |)
Street Address City State Zip Code
Birth Date (MM/DD/YYYY) Telephone Number
QI) -OD)-OD) DIDI) - OD -CC
Member ID # Relationship to the Subscriber
Self 1] Spouse[]  Child2] Other
Subscriber Information (Required)
GCE COC
First Name Middle Initial
OULD |
Street Address City State | Zip Code
Birth Date (MM/DD/YYYY) Telephone Number
LIL]- i DUO DUD -D00- OO)
Vision Plan Name Vision Plan/Group ID # Subscriber ID #
Date of Service (Required) (MM/DD/¥YYY)
DO-O0)-O00O
Request For Reimbursement —Please Enter Amount Charged. Remember to include copies of itemized expenses:
Exam Frame Lenses
8 8 s
Iflenses were purchased, please check type: L] Single LJ Bifocal [] Trifocal [] Progressive
Contact Lenses - (please submit all contact related
s charges at the same time)
Thereby understand that without prior authorization from Humana for services rendered, I may be denied reimbursement for
submitted vision care services for which I am not eligible. I hereby authorize any insurance company, organization employer,
ophthalmologist, optometrist, and optician to release any information with respect to this claim. I certify that the information
furnished by me in support of this claim is true and correct
Member/Guardian/Patient Signature (not a minor) Date:
Humana VCP Gen Pop
Out of Network HUMANA.
Vision Services Claim Form
FRAUD WARNING STATEMENTS:
Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company
‘may be prosecuted unde state law.
Arizona: For your protection Arizona law requires the following statement to appear on this form, Any person who knowingly presents a false or fraudulent claim for
‘payment ofa loss is subject to eriminal and evi penalties.
Arkansas: Any person who knowingly presents a fae or faudulent claim for payment ofa loss or benefit or knowingly presents fase information in an application for
insurance s guilty of a crime and may be subject to ines and confinement in prison,
California: For your protection Catifomia la require the following to appear on this form: Any person who knowingly presents fuse or fraudulent claim for the payment
‘of a loss is guilty ofa crime and may be subject to fines and confinement in state prison,
Colorado: Its unlawful to knowingly provide fale, incomplete, or misleading facts or information to an insurance company fr the purpose of defiauding or attempting 10
<efinud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages, Any insurance company of agent of an insurance company who
Jnowingly provides false, incomplete or misleading foes or information toa policyholder or claimant forthe purpose of defrauding or attempting to defraud a policyholder
‘or claimant with regard to a sellement or award payable from insurance proceeds shall be reported to the Colorado Department of Insurance within the department of
regulatory agencies.
Delaware: Any person who knowingly, and with intent to injure, defiaud or deceive any insurer, files statement of claim containing any fase, incomplete or misleading
information is guity of a felony.
District of Columbia: WARNING: It isa crime to provide false or misleading information to an insurer for she purpose of defrauding the insurer or any other person
Penalties include imprisonment andor fines. In addition, an insuret may deny insurance benefits if false information materially related toa elaim was provided by the
applicant
Florida: Any person who knowingly and with intent to injure, defaud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or
‘misleading information i guilty ofa felony’ of the third degree
Hawaii: For your protection, Hava law requires you to be informed that presenting a fraudulent claim for payment ofa loss or bene!
imprisonment, or both
Idaho: Any person who knowingly and with intent to deaud or deceive any insurance company,
information & guilty ofa felony.
Indiana: person who knowingly and with intent to deffaud an insurer
felony.
Kansas: Any person who, with intent to defraud or know
deceptive statement may be guilty of insurance fraud,
Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application or claim for insurance containing any
‘materially false information or conceals, for the purpose of misleading, information concerning any fist material thereto commits a faudulent insurance act, which i a
Louisiana: Any person who knowingly presents a fae or faudulent claim for payment oF a loss of benefit or knowingly presents false information in an application for
insurance is guilty ofa crime and may be subject to fines and confinement in prison.
Maine: Is a crime to knowingly provide fs, incomplete or misleading information to an insurance company forthe purpose of Jeffauding the company. Penalties may
include imprisonment, fines or deta of insurance benef,
Maryland: Any person who knowingly and willfully resents a false or fraudulent claim for payment of Toss or benefit or who knowingly and willfilly presents false
information in an application for insurance is guilty of crime and may be subject to fines and confinement in prison
Minnesota: person who ils claim with intent to deffaud or helps commit a fraud against an insurer is guilty ofa exime
[Now Hampshire: Any person, who, with a purpose to injure, defraud or deceive any insurance company, files a statement of elim containing any false incomplete oF
‘misleading information is subject to prosecution and punishment for insurance frau, a provided in § 638.20.
‘New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information i subject to criminal and eivil penalties
[New Mexico: Any person who knowingly presents a file or fraudulent claim for payment ofa loss or benefit or knowingly presents false information in an application for
insurance is guilty of a erime and may be subject o civil fines and criminal penalties
[New York: Any person who knowingly and with intent to defiaud insurance company or other person fils an application for insurance or statement oF claim containing any
‘materially false information or conceals forthe purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is aerime
and shall ao be subject a evil penalty not to exceed 5,000 and the stated value of the claim for each such violation,
‘Ohio: Any pesson who, with intent to defzaud, of knowing that he is Facilitating a fraud against an insurer, submits an application or files a false claim containing a fake or
<eceptive statement is guilty of insurance frau,
Okfahoma: WARNING: Any person who knowingly and with intent fo injure, deftaud, or deceive any inser makes any claim for the proceeds ofan insurance poly
containing any alse, incompete or misleading informatio is guilty ofa felony
‘Oregon: Any person who Knowingly and with intent to injure, defraud, or deceive any insurer files statement of la
‘misleading information may be guilty of a felony ofthe thd degre.
Pennsylvania: Any person who knovvingly and with intent to deffaud any’ insurance company or other person files an applization for insurance or statement of claim
containing any matsrally false information or conceals forthe purpose of misleading, information concerning any fat material thereto commits a fraudulent insurance as,
‘whieh i a crime and subjects such person to criminal and eivil penalties.
Puerto Rico: Any person who knowingly and with the intention of deftauding presents false information in an insurance application, or presents, helps, or causes the
presentation of fraudulent claim forthe payment ofa loss or any other benefit, or presents more than one claim forthe same damage or oss, shall incur a felony and, upon
‘conviction, shall he sanctioned foreach violation with the penalty ofa fine of ot les than five thousand (5,000) dolar and not more than ten thousand 10,000) dollars, oa
fixed term of imprisonment for three (3) years, or both penalties. Should aggravating eireumstanees are present, the penalty thus established may be inereased toa maximum
of five (5) years, if extenuating circumstances are presen, it may be reduced to a minimum of two (2) years.
Rhode Island: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
insurance s guilty of crime and maybe subject to ines and confinement in prison
‘Tennessee: It sa crime to knowingly provide false, incomplete or misleading information to an insurance company forthe purpose of deftauding the company. Penalties
include imprisonment, ines and denial of insurance benef.
‘Texas: Any person who knowingly presents a false or fraudulent claim for the payment ofa loss is guilty ofa erime and may be subject to fines and confinement in
prison,
Virginia: tis a crime to knowingly provide false, incomplete of misleading information to an insurance company fr the purpose of deffsuding the company. Penalties
‘include imprisonment, fins and denial of insurance benef.
‘Washington: It sa crime to knowingly provide false, incomplete, or misleading information to an insurance company forthe purpose of deauding the company. Penalties
‘include imprisonment, fines, and denial of insurance benefit
‘West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of
insurance is guilty ofa crime and may be subject o fines and confinement in prison,
claim containing false, incomplete, or misleading information
is a crime punishable by fines or
files a statement or claim containing a false, incomplete or misleading
+s statement of claim containing any false, incomplete or misleading information commits a
that helshe is facilitating a froud against an insurer, submits an application or files a claim containing a false or
‘ran application containing any false, incomplete, or
se informa
1 in an application for
loss or benefit or knowingly presents false information in an application for